Airbus Product Safety

Frédéric COMBES
Head of Accident / Incident Investigation

Crew Monitoring
ESASI MILAN 2014
ESASI MILAN 2014

Content

• Setting the scene

• Study cases

• What is monitoring?

• What are the challenges to effective monitoring?

• Strategies to enhance monitoring

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ESASI MILAN 2014

Setting the scene - Monitoring

• It is not natural even if it seems easy and intuitive

• Humans are not good at it!
• Monitoring is not a stand alone mechanism
• It is not specifically trained

• Training focuses on “actions” rather than monitoring

• Slowly changing parameters are not as attention getting as
an alarm or a big failure
• Delaying some tasks may be needed
• It is not natural to stop doing something in the middle

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ESASI MILAN 2014

Setting the scene - Monitoring

Several studies have demonstrated

• Monitoring is an under estimated task

• When both pilots are involved in non-monitoring tasks, the risks increase

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ESASI MILAN 2014

Content

• Setting the scene

• Study cases

• What is monitoring?

• What are the challenges to effective monitoring?

• Strategies to enhance monitoring

Page 5

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ESASI MILAN 2014

Study Cases - Content

• Study case 1 – A321 alpha protection activation in approach

• Study case 2 – A310 LOC mode reversion
• Study case 3 – A330 Rejected Take Off

• Summary

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Study case 1 - A321 alpha protection activation in approach

Initial conditions
• AP1, A/THR and FD engaged , Open Des
• Conf Clean
• Speed 250kts
• On descent from FL 90 to FL 60, ATC requested the crew to descend to 4000 ft, to be level
between 18 and 20 nm

• Crew decision to accelerate the descent :

• Speed brakes not usable due to SEC1 being unserviceable
• Thrust Levers : To IDLE, leading to A/THR disengagement

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Study case 1 - A321 alpha protection activation in approach

Mixed flying situation : AP ON, A/THR OFF

• Time Zero (T0) -Speed selected to 220 kts (following ATC request)
• Reaching 4,000ft , ALT mode engaged
 IDLE thrust not enough to maintain speed in level flight
 Gradual increase of angle of attack

T0 + 32 sec
• Actual speed below selected speed
• Altitude maintained at 4,000ft
• ATC announced Traffic “12 o’clock, 7NM, opposing route”
 Crew focused on looking outside simultaneously
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ESASI MILAN 2014

Study case 1 - A321 alpha protection activation in approach

T0 + 1m 05s – High Angle of Attack protection triggered
• AP disconnection
• Speed at 177kts (VLS - 26kts)
 Crew inputs:
Thrust Levers to CLB
Pitch up inputs for about 10 seconds since the AC was in descent
Priority to maintain the Altitude at 4,000ft
•Minimum speed reached : 172kts with descent rate at 1,000ft/mn
T0 +1m 15s
• Thrust started to stabilise
• Thrust levers set to FLEX/MCT
• Pitch up inputs maintained
• Minimum altitude reached : 3,840ft QNH
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Study case 1 - A321 alpha protection activation in approach

T0 + 1m 20s
• Maximum pitch reached : 11°
 Crew inputs:
Pitch down inputs in order to counteract pitch up moments
•Deactivation of high angle of attack protection
Not detected by the crew
End of the event
• Pitch and AoA stabilised at 3°
• Selected Speed and Altitude reached
• Uneventful landing

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ESASI MILAN 2014

Content

• Study case 1 – A321 alpha protection activation in approach

• Study case 2 – A310 LOC mode reversion
• Study case 3 – A330 Rejected Take Off

• Summary

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ESASI MILAN 2014

Study case 2 – A310 LOC mode reversion

• A310 ILS approach, while approaching the Glide Slope with AP2 engaged (LAND Mode armed,
LOC Track mode)
• Lateral mode reversion from LOC to HDG with GS mode engaged
• Late detection of lateral mode reversion at 200ft
• Go around performed
• Final approach performed with both AP’s engaged

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ESASI MILAN 2014

Study case 2 – A310 LOC mode reversion

Initial conditions
• AP2 engaged, then AP1 engaged with SPD GS* LOC FD1
CMD1
LAND mode armed
• FD engaged
• LOC engaged
• At 3500ft aircraft stabilized
on the LOC and 3500
approaching the Glide Slope

3550

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ESASI MILAN 2014

Study case 2 – A310 LOC mode reversion

T0 +3.5 sec
• At Glide Slope capture, AP2 disconnected due to SPD GS
GS* HDG
LOC FD1
second press on the LAND Pushbutton CMD1

• Lateral mode reversion

from LOC to HDG hold
mode
3500

• Glide Track remained engaged with LOC mode

disengaged 3510
• due to simultaneous engagement of Glide
capture mode with the loss of Land mode

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ESASI MILAN 2014

Study case 2 – A310 LOC mode reversion

Initial Approach
• AP1 and FD engaged SPD GS HDG FD1
CMD1
• In Glide Track and Heading hold modes ,

Manual Go Around at 200ft

Final Approach
250
• Both AP’s engaged
• Uneventful landing performed
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ESASI MILAN 2014

Content

• Study case 1 – A321 alpha protection activation in approach

• Study case 2 – A310 LOC mode reversion
• Study case 3 – A330 Rejected Take Off

• Summary

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ESASI MILAN 2014

Study case 3 – A330 Rejected Take Off

• A330 RTO performed by the crew at a speed of 112kts following RH engine surge
• Day condition and dry runway
• The right engine failed emitting a flash and smoke from the exhaust
• FO PF, CAPT PM
• Crew quickly established that there was a loss of power and aborted Take Off
• Emergency stop on the runway and taxi clear using the unaffected left engine.

• Video from internet

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Study case 3 – A330 Rejected Take Off

223T/29.1% (97% MTOW / MED CG)
T0+30” 825m V1min no wind = 129.7kts
FLEX 40°C CAS max. 113kt V1max = VR = 144.5kts
CONF2 T0+28.1” 760m Deviation lateral max. 3.7m V2 = 150.8kts
RTO: REV MAX in 1”
112kt=V1min-18kts T0+35” 1065m
GS extension / Autobrake activation 50kt
Thrust levers selected to REV IDLE
T0+27.9” 700m
112kt=VMCG+4.5kts T0+37” 1110m
Rudder pedal input up to 33° (95% from maxi) 40kt
Thrust levers selected to IDLE
T0+27.1” 660m GS deselection 1 sec after
107kt A/BRK OFF- Manual braking
Actual N1% #2 sharp decrease
Ny sharp variation up to -0.06g
T0+42” Engine Fire Handle selection
T0+26” 580m
100kt
N1 84% stable
T0 -135m T0+51” 1260m
Thrust levers FLEX AC stopped

Time
ASDA=2897m

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ESASI MILAN 2014

Study case 3 – A330 Rejected Take Off

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Summary of study cases

• Monitoring by PF/PM is key to the timely detection of issues and initiation of

appropriate actions

• The first two examples demonstrate the importance of monitoring mode

annunciations (Golden Rule No 1)

• The “normal” eye scan must also include basic flight parameters
(pitch, thrust, speed…)

• In the third example other senses (sound, body accelerations) were also used to
monitor and to trigger action

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ESASI MILAN 2014

Content

• Setting the scene

• Study cases

• What is monitoring?

• What are the challenges to effective monitoring?

• Strategies to enhance monitoring

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ESASI MILAN 2014

What is monitoring?

• “Fly, navigate, communicate” requires the crew to be aware of evolving information of

different natures and with different time spans
• Aircraft
• Flight path
• Environment & context
• Crew members
• In a dynamic environment
• Evolving constraints
• You need “at the same time“ to focus on the
• Big picture
• Attention to specific details
• Evolving information
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Monitoring is not a “stand alone” mechanism

Monitoring To be aware of the state of something. But of what?

When you monitor you compare the information against

Monitoring
your expectations
against
Expectations are based on your mental model which in
expectations
turn is based on knowledge and experience

Expectations Expectations form part of your situation awareness and

within Situation attention mechanisms
awareness • Knowing what is going on around you
• Being able to continuously update

Objectives Accurate Situation awareness is essential to achieve

YOUR GOAL
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ESASI MILAN 2014

Content

• Setting the scene

• Study cases

• What is monitoring?

• What are the challenges to effective monitoring?

• Strategies to enhance monitoring

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ESASI MILAN 2014

The challenges of monitoring

• Organizing the information with priorities towards a shared goal and action plan

• Knowing and agreeing what is

• Important versus Urgent
• Seek information –using all your senses
• Know WHAT is important,
• WHEN to seek it
• WHERE to find it
• Check it
• And share it

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ESASI MILAN 2014

The challenges of monitoring – the traps

• Not enough importance on monitoring skills during training

• Ex: call-out, cross-check, scanning…
• Routines accepted within a fleet or an airline

• Focalisation
• your attention is caught and you forget the rest
• Dispersion
• “you jump” from one information to another and you become overcome by the
context
• Distractions / Interruptions
• Fatigue
• Complacency

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ESASI MILAN 2014

Content

• Setting the scene

• Study cases

• What is monitoring?

• What are the challenges to effective monitoring?

• Strategies to enhance monitoring

Page 27

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ESASI MILAN 2014

Strategies

• Review task in advance to anticipate potential problems and adjust monitoring

• Recognize multitask demands and decide how to divide attention between them

• Share perception in vulnerable situations and increase vigilance

• Manage workload

• Active monitoring may be improved when you concentrate on “mentally flying the
aircraft” even when the AP is ON

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ESASI MILAN 2014

Strategies

• Adapt the monitoring of parameters / information to the speed of their evolution

• All information does not evolve at the same speed

• Make risk assessments

• Ask “what if?”

• Assign monitoring tasks at least an equal or even higher priority than the other tasks
in the flightdeck

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ESASI MILAN 2014

Conclusion

Mental picture / plan Task set

• intentions • What?
• how to achieve • When?
Briefing • what to monitor • How?
and • typical failures Situation awareness
Preparation •... Procedures

Capture of aircraft information Teamwork and communication

• flight parameters
• FMA
Communication
•…...
Call out Call out
Cross check Crosscheck
Scanning Task-sharing

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ESASI MILAN 2014

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